falkirk integrated plan · the falkirk wheel and the kelpies have promoted the area across the...
TRANSCRIPT
Falkirk Integrated Strategic Plan2016-2019
Content
Setting the scene 4
A Plan for Falkirk area 6
Why change? 13
People’s view 20
How will this plan 22be delivered?
3
Foreword
To enable people to live full, independent and positivelives within supportive communities.The integration of Health and Social Care will see the establishment of a Falkirk Healthand Social Care Integration (HSCI) Partnership with its own Integration Joint Board,developed by Falkirk Council and NHS Forth Valley.
We are pleased to introduce our first Strategic Plan on behalf of the HSCI Partnership. This plan is of interest to people living in the Falkirk area as it describes how we willdeliver services to adults who use health and social care services. The plan will bereviewed every year.
New legislation requires that a local plan is produced to ensure that people who usehealth and social care services get the right care and support, whatever their needs, atany point in their care journey.
In the future, we need to build on our existing partnerships and develop new relationshipswith people, communities, our workforce and other stakeholders. The main purpose of theHSCI Partnership is to put people at the centre of decisions about their care and support.It will build on current good practice to change the way we deliver services that are highquality and joined up to meet individual need.
This will “enable people to live full, independent and positive lives within supportivecommunities” forming Falkirk’s Strategic Plan vision.
This is an opportunity for the new HSCI Partnership to use our combined resources in amore effective, efficient and person-centred way. This will mean that we can address thechallenges we face. There is an increased demand on services that will exceed availableresources if we do not work together in a more integrated way. This will ensure a jointcontribution to encouraging, supporting and maintaining the health and wellbeing ofpeople who live in our community.
We should celebrate that people are living longer, are active and contributing citizens, and in the main are healthier or are able to live at home with long-term and multipleconditions. However, there are inequalities within our local communities, which we aim to address by working with our partners to prevent and reduce the impact of poverty,promote equality of access, and improve health and well-being. Equality will be at theheart of everything that we do.
The HSCI Partnership will focus on prevention and early intervention. We will encourageand support self-management so that people are in control of their own health and care to be as independent as possible and enhance their quality of life.
We want to change the way we deliver services and to involve people in how services are redesigned to meet their needs. Our three year Strategic Plan is informed by a range of engagement and consultation activity and local and national information. We will putpeople first and combine our resources to provide integrated support, and engage withcommunities and staff to deliver on locality plans.
On behalf of Falkirk Health & Social Care Partnership
Allyson Black, Chair, Patricia CassidyFalkirk Integration Chief OfficerJoint Board
1: Setting the scene
People will be at the centre of all decisions abouttheir care and support. When this support isprovided, the HSCI Partnership will ensure this isdelivered to the highest quality and safetystandards. We will work with people with a focuson prevention, anticipation and supported self-management. When admission to hospital isrequired, there will be a focus on ensuring peopleare supported to return to their home. This will bedone as soon as appropriate to ensure there isminimal risk of re-admission to hospital.
The Scottish Government’s 2020 Vision is that by2020 everyone is able to live longer healthier livesat home, or in a homely setting. This vision willonly become a reality by all agencies workingtogether. To make this new way of workingsuccessful, it is essential that the views of serviceusers, their carers and families and localcommunities are taken into account in shapingfuture services.
The Public Bodies (Joint Working) (Scotland) Act2014 requires NHS Boards and Local Authorities toestablish Health and Social Care Partnerships. InFalkirk it has been agreed to deliver integratedhealth and social care services through delegationto an Integration Joint Board. The Board isestablished as a body corporate, with theappointment of a Chief Officer as the jointlyaccountable officer.
The Integration Joint Board was established on 3October 2015 and has representatives from FalkirkCouncil, NHS Forth Valley, Third Sector, service usersand carers. From 1 April 2016, the Integration JointBoard, through its Chief Officer, will haveresponsibility for the planning, resourcing and theoperational oversight of a wide range of health andsocial care services.
The HSCI Partnership, consists of the LocalAuthority, NHS Forth Valley, Third and Independentsectors, who will work together to provide effectiveand joined up services. The partnership will work
towards the 2020 Vision in an integrated way andare responsible for the delivery of targets, called theNational Health and Wellbeing Outcomes.
In addition, as a statutory member of Falkirk’sCommunity Planning Partnership, the HSCIPartnership has a key role. Specifically this will bein contributing to the delivery of the strategicpriorities and outcomes contained in the StrategicOutcomes and Local Delivery Plan. The HSCIPartnership will take into account our role insupporting adults and considering the impact onyoung people and families, making the necessaryconnections across strategic planning and servicedelivery.
The HSCI Partnership will prioritise services inresponse to the key issues set out in Section 3 andthe detailed Joint Strategic Needs Assessment(JSNA).
The key issues for the Falkirk area are:• there is an ageing population• there are growing numbers of people living withlong term conditions, multiple conditions andcomplex needs
• early intervention and prevention can make adifference
• carers support• workforce• deprivation, housing and employment.
NHS Forth Valley and Falkirk Council are building onexisting working practices that will put in placeintegrated working arrangements. In doing so wewill continue to ensure we make connections withother partnerships. These will aim to provide better,more seamless adult health and social care services.Integration of these services is driven, in part, bythe following:• People in Falkirk would like to have access tomore joined up care and support near home
• More people in Falkirk are living longer with arange of conditions and illness
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• Local demand for existing health and social careservices is changing and there are resourceconstraints in terms of human and financialresources
• NHS Forth Valley and Falkirk Council mustcontinuously improve services and contribute toachieving better outcomes for people
• There is an opportunity to make better use ofpublic resources while creating increased publicvalue in avoiding duplication of effort.
Falkirk HSCI Partnership and Localities The HSCI Partnership has identified its locality areasfor service planning purposes. This is required in thelegislation. There will be three localities within theFalkirk Council area:
Falkirk
The Falkirk Locality is the smallest and mostcompact of the three Heath and Social CareLocalities with a population (including Hallglen) of just under 40,000. It is centred on the ancientburgh of Falkirk itself which is the main retail andadministrative centre for the Council area as well as having the main campus of Forth Valley College.Falkirk town centre is a main source of employmentand other major employers are the public sector andvehicle manufacturing. Some of the most deprivedareas within the Council area lie in Falkirk, inparticular parts of Camelon, Bainsford and Langlees,as well as in Hallglen. The recent major projects ofthe Falkirk Wheel and the Kelpies have promoted thearea across the whole of Scotland and beyond.
Grangemouth, Bo’ness and Braes
This is the largest of the three Heath and SocialCare Localities, both in terms of area (176 sq km)and population (over 65,000). It lies along thecoastline of the River Forth and extends southwardsinto the higher land of the Slamannan Plateau. It contains the former burghs of Grangemouth and Bo’ness as well as the villages of the Braes such asPolmont, Westquarter,
Redding and the more isolated villages such asSlamannan and Avonbridge. Grangemouth is amajor industrial town based largely on the petro-chemical industry and is also Scotland’s premierport.
The M9 motorway runs through the area and theKincardine and Clackmannanshire bridges connectthe area to Fife and beyond. The locality includessome of the Falkirk Council area’s most prosperousestates as well as areas of deprivation inGrangemouth, Bo’ness, Maddiston, Westquarter andSlamannan. The Braes area is a popular location forhome buyers and considerable housing developmenthas taken place and is expected to continue.
Denny/Bonnybridge/Larbert/Stenhousemuir
This Health and Social Care Locality lies in the northwest of the Council area and has a population ofaround 53,000. It includes the towns of Denny,Bonnybridge, Larbert and Stenhousemuir and anumber of smaller settlements. The population isgrowing with major new housing developments inDenny and Larbert. Forth Valley Royal Hospital is amajor employer and is located close to themotorway network with the M80 and M876connecting the area to the rest of Scotland.There are small pockets of deprivation in Dennyand Stenhousemuir but this is a fairly prosperousarea which has good commuting links.
This Strategic Plan describes why, what and howhealth and social care services will be configured.This plan presents a framework to deliver the agreedvision over the following three years and will bereviewed each year. A number of key priorities havebeen identified, which will help provide a directionand focus for service change and improvement.
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Figure 1: Falkirk Health andSocial Care Locality Areas
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This section summarises the vision and theconnections between this and the principles,outcomes and priorities that have been identified.
2.1 VisionThe Falkirk HSCI Partnership agreed vision isdescribed as:To enable people in Falkirk to live full andpositive lives within supportive communities.
2.2 Outcomes and PrioritiesThe HSCI Partnership has identified five specificoutcomes for the Falkirk Strategic Plan andIntegration Scheme. These are in line with theScottish Government’s 2020 Vision and are:
• Self-Management: Individuals, carers andfamilies are enabled to manage their own health,care and wellbeing
• Autonomy and Decision Making: Where formalsupport is needed people should be able toexercise as much control and choice as possibleover what is provided
• Safe: Health and social care support systems arein place, to help keep people safe and live wellfor longer
• Service User Experience: People have a fair andpositive experience of health and social care
• Community Based Support: Informal supportsare in place, which enable people, where possible,to live well for longer at home or in homelysettings within their community
The local outcomes address the key challengeshighlighted in the Joint Strategic Needs Assessment(JSNA) (as outlined in section 3). The outcomes arealso consistent with the views of people who useservices, their carers and communities. This plan isfor adults and older people who have a range ofhealth and care needs. These include physicaldisability, mental health, complex care needs,learning disability, long term conditions, alcohol
and substance misuse, and young people movinginto adult services.
The Falkirk HSCI Partnership will focus on theidentified priorities in the Strategic Plan to achieveits outcomes. These are set out in sections 2.4 –2.8. The delivery of these priorities will support thetransformational change that will be needed todeliver integrated services.
2.3 What will be differentBy services working together in a much moreintegrated way, the outcomes for people usinghealth and social care services will be improved.This will also avoid duplication, improvecommunication and understanding of services andreduce dependency.
Table 2:Illustration of old and new care model.Adjusted from Falkirk Joint Commissioning Plan forOlder People 2014 - 2107
Current Model of Care Future Model of Care
Disjointed care Integrated, seamless carewith a single point ofcontact
Reactive care Preventative andanticipatory care
Acute centred Embedded incommunities
Services are given topeople
Services empower peopleto self-manage
Service user aspassive recipient
Service user as partner
Support for carers isvariable
Equitable support forcarers
Under use oftechnology
Improved use oftechnology
Acute condition focus Long-term conditionfocus
2: A plan for the Falkirk area
2.4 Local Outcome OneSelf-Management: Individuals, carers and families are enabled to manage their own health, care and wellbeing.
What does this mean for people?People, their carers and families are at the centre of their owncare by prioritising the provision of support which meets thepersonal outcomes they have identified as most important tothem. Services will encourage independence by focusing onreablement, rehabilitation and recovery.
People are able to access services quickly via a single point ofcontact. Information that enables people to manage theircondition is accessible and presented in a consistent way. Thiswill include a range of information on services and communitybased supports.
In addition, services are responsive and available consistentlythroughout the year, on a 24/7 basis, if appropriate.
What does this mean for our communities?Communities will feel they are involved in decisions that affectthem. Their views are gathered and they are listened to. Theyknow what services we have available to provide and haveconfidence in them.
What does this mean for the HSCI Partnership?Our shared vision is held across all partners. Our workforceacross all sectors is highly skilled and has a focus on promotingindependence and improving health and well-being. Jointworking across agencies and sectors is the norm and frontlinestaff are empowered to take decisions, which allows them totailor response and care to suit the needs of the people.
What are we going to do?• We will lead the cultural change requiredacross agencies and communities to supportthe change necessary to deliver integratedcare
• We will redesign services so they are flexibleand responsive, ensure feedback drivescontinuous improvement and are aligned toour outcomes
• We will continue to develop the ways inwhich we support carers
• We will support people to use technologysolutions to support them to have moreindependence and control over their lifestylesand the management of their condition
• We will implement our Integrated WorkforcePlan to support our staff and partnersthrough training and organisationaldevelopment
• Communication will be central to everythingthat we do. We will continue to engage withstakeholders to shape our services to meetneeds
• We will provide information that enablespeople to manage their condition and isaccessible and delivered consistently
2.5 Local Outcome TwoAutonomy And Decision Making: Where formal support is needed people are able to exercise as much controland choice as possible over what is provided.
What does this mean for people?Health education and information is accessible and readily available topeople, their carers and families, which allows them to make informedchoices and manage their own health and wellbeing. Person-centredcare is reinforced acknowledging family/carer views. Care and supportis underpinned by informed choices and decision making throughoutlife.
What does this mean for our communities?Communities are enabled to continue to develop and manage a varietyof good quality local services to meet community need.
What does this mean for the HSCI Partnership?Information sharing is critical to good integrated care and is extendedacross all sectors. Information sharing includes the ability to sharesingle assessments and care plans. These will be co-produced byservice users and professionals, and can be used and updated acrossprofessional specialism. This allows the co-ordination of care, so thatthe right care is provided at the right time by the most appropriateservice.
Infrastructure, particularly IT systems, are in place to support this, andstaff are able to securely access and use the system with data sharingprocedures in place. Information is shared appropriately to ensure asafe transition between all services.
What are we going to do?• We will develop a single point ofcontact for people and their carers tosupport access to a wide range ofinformation on services across allsectors
• We will develop one Single SharedAssessment as standard across thePartnership
• We will promote the uptake ofAnticipatory Care Plans that reflectthe current views of people and theircarers. We will ensure this informationis shared where appropriate
• We will continue to design communitybased models of care, such as Closerto Home and Advice Line For You(ALFY)
• Information sharing protocols are inplace
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2.6 Local Outcome Three
Safe: Health and social care support systems are in place, to help keep people safe and live well forlonger.
What does this mean for people?People will be supported to live safely in their homes andcommunities. People will be involved and consulted ondecisions about their care, treatment and support. People willhave timely access to services, based on assessed need.Services will improve qualities of lives and be joined up tomake best use of available resources.
What does this mean for our communities?Communities are confident that systems are in place for theidentification, reporting, and prevention of harm.
What does this mean for the HSCI Partnership?The Partnership is able to identify, manage and tolerate risk,and staff are supported in being able to work in differentways, to support personal outcomes.
The Partnership recognise the critical link between health andsocial care provision and the contribution of wider partners,for example, the Community Planning Partnership, CriminalJustice and Housing.
The Partnership will continue to ensure there are robustsystems in place to review the effectiveness of arrangementsin place to support the delivery of safe, effective and personcentred services. This will be through, for example the ClinicalCare Governance Framework and the Adult Support andProtection Committee.
The Partnership will continue to work together to reduceavoidable admissions to hospital by ensuring that priority isgiven to strengthening community based supports.
What are we going to do?• We will ensure there is a greaterfocus given to individual casemanagement, enhanced by theprovision of advocacy support, whererequired
• We will ensure risk is acknowledgedand managed effectively and riskbased support is in place
• We will continue to work across thepartnership to ensure adults at riskof harm are supported and protected
• We will implement our Clinical CareGovernance framework
• We will continue to invest inTechnology Enabled Care as aneffective and appropriate way tosupport care
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2.7 Local Outcome Four
Service User Experience: People have a fair and positive experience of health and social care.
What does this mean for people?People feel services are responsive to their needs and areavailable to them before reaching a point of crisis. Theseservices are joined up and improve quality of lives. People areengaged and involved across the HSCI Partnership. People willreceive feedback and understand what their contribution hasinfluenced.
What does this mean for our communities?Communities will have the opportunity to be engaged andinvolved in service redesign and delivery within their localareas. This will be based on a clear understanding of localneeds and available resources.
What does this mean for the HSCI Partnership?The Partnership will enable its workforce to be motivated tocome to work, feel supported by colleagues and management,and valued by colleagues and people for whom they providecare. We will encourage continuous improvement by supportingand developing our workforce.
What are we going to do?• We will ensure consistent highquality services are delivered,informed by a robust serviceevaluation framework
• We will ensure our decision-makingprocesses are consistent, fair andtransparent, and are based onreliable information and evidencebased good practice
• We will complete Equality andPoverty Impact Assessments for allsubsequent changes to policies andservices to ensure we identify andaddress inequalities
• We will implement our Participationand Engagement Strategy
• We will pursue co-location of staffand services where appropriate tosupport integration
2.8 Local Outcome Five
Community Based Supports: Informal supports are in place, which enable people, where possible, tolive well for longer at home or in homely settings within their community.
What does this mean for people?People are more confident, reliant and able to access localservices and support to improve and maintain their health andwell-being and be more independent. There will be a focus onearly intervention and prevention.
What does this mean for our communities?Communities are informed, involved and supported to workcohesively to develop and manage community based supports.
What does this mean for the HSCI Partnership?The Partnership will work pro-actively with the CommunityPlanning Partnership and the Third Sector and IndependentSector to plan and deliver solution based and communityfocussed services to support the delivery of our priorities.
What are we going to do?• We will establish locality planningstructures within the three localareas agreed which will align withthe Community Planning Partnership
• We will adopt a consistent frameworkwhen commissioning services thatwill build sustainable capacity withinall sectors
• We will build on existing strengthswithin local communities
• We will provide information aboutcommunity based support that isaccessible and presented in aconsistent manner
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2.9 Summary table showing the links from the national Health and Well-being Outcomes to local priorities
Local Outcomes
Self-Management:Individuals, carers and families are enabled to managetheir own health, care and wellbeing
Autonomy And Decision Making:Where formal support is needed people should be ableto exercise as much control and choice as possibleover what is provided
Safe:Health and social care support systems are in place,to help keep people safe and live well for longer
Service User Experience:People have a fair and positive experience of healthand social care
Community-based Supports:Informal supports are in place, which enable people,where possible, to live well for longer at home or inhomely settings within their community
Evidence
Population, with +75 expected to double by 2037People with multiple conditionsLife expectancy for people with conditionsLifestyle risks such as obesity, smoking andsubstance misuse
• +15,000 Carers in Falkirk area of which 37%provide 35 hours care per week
• 2.3% patients account for 50% health expenditure- most with 2-4 conditions.Emergency admissions to hospitalDelayed Discharges, with 1,034 bed days lost inJuly 2015
• An average of 6,848 items of equipment areprovided per annum to support people to live athomeIn 2014, 4,353 people received telecare services
• 990 adults with Learning Disabilities in Falkirk area,51.1% live in mainstream accommodation
• 10,868 adults with physical disability, 53% aged50-74.
In working age population, which is mirrored inPartnership workforce
• Heath & Care recipients survey 13/14 found – 94%respondents felt ‘ treated with respect’ and 85%felt ‘health & social care services seem well co-ordinated’
Community engagement over 2 years to informFalkirk’s Community Learning and Development ActionPlan found:• People do not always know what services and
support is available to them in their communities• Impacts on health and wellbeing include not
feeling safe within community, isolation, issuesregarding housing and employment
• There are 18 datazones in the Falkirk Council areawhich fall within the 15% most deprived inScotland (SIMD)
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Scottish Government2020 Vision
Local Outcomes: What They mean andwhat we’re going to do
What People Said
‘More prevention work and dealing with the underlying causes of poor physical and mentalhealth. A co-ordinated approach.’
‘…working with a range of agencies including education […] physical activity providers andretailers to educate on healthy lives.’
‘A framework for dealing with medication in the community’
‘IT communication should be improved to allow sharing of information easier.’
‘better sharing of information - relatives often have to articulate care needs over and overagain’
‘More consideration is required for the transition from children’s services (health) to adultservices (social work) where disabled are concerned’
‘The process of links between the different services has been a great success so far and helpedkeep my father and mother-in-law at home longer. It made their lives better and ours too.’
‘more emphasis placed on technology enabled care to help people self manage theirconditions at home.’
‘Not all people needing help or re-homing are elderly […] More communication between staffmight make a difference’
‘Use of technology to support people to articulate their needs, provide feedback and influenceservices and plans and improve care’
‘It's taken me a year to find out where I can find support to cope […] a single point ofcontact for me would really have helped me during the year since diagnosis.’
‘dialogue between client and service staff should be open and honest at all times’
‘There also needs to be a culture of open feedback mechanisms, where errors or mistakes are--not punished, but seen as learning opportunities for the individuals and the systems’
‘Where to get information on how people can get more involved.’
‘Isolation and malnutrition need to be addressed. Incentive social activities /lunch clubs etc’
‘We…get together and run a self help group, which I think is very important, since most GP'sare just learning about it. I feel we have a lot to offer!’
Priorities
• We will lead the cultural change required across agencies andcommunities to support the change necessary to deliver integrated care
• We will redesign services so they are flexible and responsive, ensurefeedback drives continuous improvement and are aligned to our outcomes
• We will continue to develop the ways in which we support carers• We will support people to use technology solutions to support them tohave more independence and control over their lifestyles and themanagement of their condition
• We will implement our Organisational Development and Workforce Plan tosupport our staff and partners though training and organisationaldevelopment
• Communication will be central to everything that we do. We will continueto engage with stakeholders to shape our services to meet needs
• We will provide information that enables people to manage theircondition is accessible and delivered consistently
• We will develop a single point of contact for people and their carers tosupport access to a wide range of information on services across allsectors
• We will develop one Single Shared Assessment as standard across thePartnership
• We will promote the uptake of Anticipatory Care Plans that reflect thecurrent views of people and their carers. We will ensure this informationis shared where appropriate.
• We will continue to design community based models of care, such asCloser to Home and Advice Line For You (ALFY)
• Information sharing protocols are in place
• We will ensure there is a greater focus given to individual casemanagement, enhanced by the provision of advocacy support, whererequired
• We will ensure risk is acknowledged and managed effectively and riskbased support is in place
• We will continue to work across the partnership to ensure adults at riskof harm are supported and protected.
• We will implement our Clinical Care Governance framework• We will continue to invest in Technology Enabled Care as an effective andappropriate way to support care.
• We will pursue co-location of staff and services where appropriate tosupport integration
• We will ensure consistent high quality services are delivered, informed bya robust service evaluation framework
• We will ensure our decision-making processes are consistent, fair andtransparent, and are based on reliable information and evidence basedgood practice
• We will complete Equality and Poverty Impact Assessments for allsubsequent changes to policies and services to ensure we identify andaddress inequalities
• We will implement our Participation and Engagement Strategy
• We will establish locality planning structures within the three local areasagreed which will align with the Community Planning Partnership
• We will adopt a consistent framework when commissioning services thatwill build sustainable capacity within all sectors
• We will build on existing strengths within local communities• We will provide information about community based support is accessibleand presented in a consistent manner
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Case Study
Linda presented to her GP in a state of crisis. Linda had experienced suicidalthoughts on and off since adolescence,however things had become worse sincethe birth of her first child 9 months ago.Linda was struggling to cope and couldnot see a future.
Linda’s GP urgently referred her toFalkirk Community Mental Health Team(CMHT) and this was screened within 4 hours by the CMHTs rota coordinator.Based on risk, Linda was visited by 2mental health professionals (a nurse and an occupational therapist) within 48 hours.
Linda was given immediate emotionalsupport for the distress she wasexperiencing. The mental healthprofessionals devised a safety plan withLinda which detailed practical ways shecould keep herself safe during timeswhen her emotions were over whelming.
As Linda was the sole carer of a baby,the team’s social worker linked with the Health Visitor to provide support to Linda bonding with her baby. ThePsychiatrist explained her condition andgave her some written information andshe was encouraged to use some self-help materials and taught strategies tohelp her manage distress. A review ofher medication was completed with herinvolvement.
Linda’s had access to treatment andsupport and felt she had learned theskills necessary to manage. When Lindahad been able to achieve a period ofstability it was appropriate and safe for her care to be transferred back to her GP.
Linda’s case was reviewed at the weekly team meeting. During Linda’sjourney she was supported by a singleteam and as far as possible by the sameprofessionals. Linda reported gaining asense of trust in the team because ofthis approach.
Throughout Linda's journey she was seen by the same professionals as much as possible. Thisproved continuity and consistency of care. A holistic care plan was generated using the differentprofessional skills within the Community Mental Health Team (Linda was provided with evidencebased biological, psychological and social treatments). When new professionals became involvedin her care there were face to face discussions (paper bureaucracy was kept to a minimum- thisallowed professionals more time to care for her and prevented delays in getting Linda help sheneeded). Her case was discussed and reviewed regularly by senior staff from all professionaldisciplines at the weekly team meeting and this provided regular safety checks as Lindaprogressed through her treatment journey. Recovery and self-management was promoted. Whenshe was safe and ready to be moved on from secondary care services this was done so that theservice has enough capacity to help the next individual like Linda.
We already have good examples of how joined up working betweenhealth, social care, the independentand third sector can make a difference.We will continue to work with our staff,service users and carers to deliver morestreamlined and coordinated care. Thiswill lead to better outcomes for peoplewho use our services.
The following case study gives anexample of how this can be done.
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3: Why change?
The demand and expectations of our communities is changing and thus the need for services andsupports is also changing. People in our communities have increasing complexity of need. There isgreater public expectation coupled with reducing resources means the need to change significantlywhat we deliver as well as the way services are delivered.
The more traditional ways in which health and social care and support services have been structuredand delivered has not always led to improved outcomes for people ie the outcomes we want and havedescribed in this plan.This means that care is provided to people rather than supporting them to be asindependent as they can be within their own homes and in their communities. A traditional approachcan lead to unnecessary, expensive and prolonged hospital admissions with a subsequent andincreased dependency on care services. We can also provide minimal amounts of service that in facthave no demonstrable benefits for people but which do use quite a lot of resource. This approach isunsustainable and fundamental change is required.
3.1 Local Population The Falkirk Council area has a population of approximately 157,640 (2014) and is increasing. Thepopulation has been increasing for over 20 years after some years of little change. The area has grownby almost 12,500 since the Census in 2001 (8.5%) compared to an increase in Scotland of 5.6%. Wehad the ninth fastest growth rate of all Scotland’s councils.
Figure 4: 75+ population expected to nearly double by 2037Older Population = Heavy users of servicesIncreased Older Population = Increased demand for servicesNeed for service re-design
AgeGroup90+
85-89
65-6970-74
60-6455-59
35-3940-44
25-29
80-8475-79
50-5445-49
30-34
20-24
6,00
0
5,00
0
3,00
0
1,00
0
2,00
0 0
4,00
0
6,00
0
5,00
0
3,00
0
1,00
0
2,00
0
4,00
0
Falkirk Population by Age/Sex 2027Male FemaleAge
Group90+
85-89
65-6970-74
60-6455-59
35-3940-44
25-29
80-8475-79
50-5445-49
30-34
20-24
6,00
0
5,00
0
3,00
0
1,00
0
2,00
0 0
4,00
0
6,00
0
5,00
0
3,00
0
1,00
0
2,00
0
4,00
0
Male FemaleFalkirk Population by Age/Sex 2012
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3.2 Multiple and long-term conditionsMultiple morbidity is common, increases with age, and by age 65 years mostindividuals will be living with more than one diagnosed condition. It shouldbe noted that currently the number of individuals with multi morbidity isactually higher in those younger than 65 years. This highlights the need forproactive anticipatory care planning and adequate focus on prevention andpositive lifestyle interventions.
There are clear links between the onset of long term conditions and mentalhealth problems, deprivation, negative lifestyle factors and the widerdeterminants of health. People living with a long term condition are likely tobe more disadvantaged across a range of social indicators, includingemployment, educational opportunities, home ownership and income.
Individuals living in a disadvantaged area are more than twice as likely tohave a long term condition and more likely to be admitted to hospitalbecause of their condition. Furthermore, the onset of multiple morbidityoccurs 10–15 years earlier in people living in the most deprived areascompared with the most affluent.
People living with long term conditions are also more likely to experiencepsychological problems. Prolonged stress alters immunity, making illnessmore likely and recovery more difficult, especially for those who are alreadyunwell. Mental health disorders, particularly depression, are more prevalentin people with increasing numbers of physical disorders.
Number of long-term conditions by age group (Estimated for Falkirk HSCP - 2015)
Figure 5:Estimated number of people within Falkirk with various numbers of long-term conditions - 2015. Source: The Challenge of Multi-morbidity in Scotland,Professor Stewart Mercer applied to NRS population estimates for Falkirk
0
2,000
4,000
8,000
10,000
12,000
14,000
6,000
5 - 9
10 - 14
15 - 19
75 - 79
80 - 84
85+
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 4950 - 54
55 - 59
60 - 64
0 - 4
70 - 74
65 - 69
0 Conditions1 Conditions2 Conditions
3 Conditions4 Conditions5 Conditions
6 Conditions7 Conditions8 or more Conditions
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3.3 CarersThe role of carers is widely recognised as being fundamentally important insupporting people to continue to live in their own homes and communities.Carers often live with the consequences of caring: poor health and wellbeing,financial hardship and the inability to participate in activities that otherstake for granted, such as work, learning, leisure and family life. The provisionof unpaid care is a key indicator of care needs and has importantimplications for the planning and delivery of health and social care services.
There are an estimated 492,231 carers in Scotland (Census, 2011). TheCensus estimated 28,014 of these carers are within the Forth Valley area.
An overview of carers in the Falkirk area is presented below:• 15,056 people providing unpaid care in Falkirk, 9.7% of the localpopulation
• Approx. 2/3rds 35-64 years and nearly 20% over 65 years• 35.7% of carers in Falkirk provide in excess of 35 hours unpaid care• 29% of those providing in excess of 35 hours care are aged 65 and over.
The chart below builds on the idea that the health of carers is worse thanthe population who do not provide unpaid care. There is a clear patternshowing that the health status of the carer deteriorates as the level of careprovided increases. Less than 60% of those providing the highest level ofcare (50+ hours a week) consider themselves to be of good or very goodhealth, compared to over 80% who do not provide unpaid care.
Figure 6: General health by level of unpaid care provision - Falkirk, Scotland’sCensus 2011
We will:• Recognise and value carers as equal partners in care• Support and empower carers to manage their caring responsibilities withconfidence, in good health and enable them to have a life of their ownoutside of caring
• Fully engage carers as participants in the planning and shaping of servicesrequired for the service user and the support for themselves
• Ensure that carers are not disadvantaged, or discriminated against, byvirtue of being a carer
• Recognise and support the needs of any young carers who are caring for anadult.
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3.4 DeprivationDeprivation is a risk factor for the vast majority of conditions and we mustcontinue to reduce health inequalities through positive health and socialoutcomes for those experiencing deprivation.
Within the deciles, 1 is the most deprived and 10 the least deprived. Figure7 illustrates the number of people and data zones in each decile in Falkirk.The population in Falkirk can almost be split right down the middle, half ofthe population live in the lowest five deciles, and the other half in thehighest five deciles.
Figure 7: Falkirk area population by SIMD decile. Source: SIMD 2012
3.5 WorkforceThe local demographics demonstrate an ageing workforce; subsequently theFalkirk Partnership must consider the workforce to ensure that plannedfuture services are sustainable. The raising of the retirement age alsoemphasises the need to develop strategies which meet individual and theFalkirk Partnership’s expectations; enabling people to work longer with bothenergy and good health so that vital skills are retained.
The Falkirk Partnership aims to improve working lives through provisions tocreate better work/life integration. Flexible working practices can enablepeople to be refreshed and committed throughout their working lives.
The Partnership will support the delivery of new ways of working forservices providing health and social care. A Staff-side Framework is agreedand working to achieve positive involvement with staff-side organisationsand with all staff. The Partnership continues to work together in developingeffective integrated health and social care teams working across systems.Joint Organisational Development work is well positioned and is alreadysupporting the development of joint planning and working.
Mapping the workforce with all partners is key to the delivery of theintegration agenda and partners are committed to working together tosupport this process. A framework of Human Resources metrics has beenagreed and in time, integrated workforce plans in support of new andemerging models of care will be developed.
Population Number of datazones
PopulationNumber ofdatazones
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The continuing focus is on the development of relationships and working arrangements withpartners which will deliver the conditions required for success in the Integration of Health andSocial Care agenda.
Figure 8:Workforce age profiles for NHS Forth Valley and Falkirk Council – September 2015 Source: ScottishWorkforce Information Standard System (SWISS) & Falkirk CouncilNote – NHS Forth Valley figures represent the entire workforce, not just those in scope for integration, itis assumed that the relevant staff will share a similar age profile.
3.6 Emergency Hospital AdmissionsThe delivery of emergency and urgent care is becoming increasingly challenging due to a range offactors such as the ageing population, increasing numbers of people with complex conditions andchanges in the availability of the workforce to deliver care (CSR, 2015). Figure 9 demonstratesthat the rate and number of admissions remains below the Scottish average. Figure 10 shows thenumber of emergency hospital admissions for patients aged 65+ from 2004/5 to 2013/14 whichhas increased.
Figure 9: Falkirk emergency admissions to hospital - 2004/05 to 2013/14. Source: ISD Scotland As the numbers of older people increase, the number of hospital admissions is likely to increase.For example, Figure 10 demonstrates that 65+ year olds represent over a third of emergencyadmissions. Therefore, there is a need to reduce the rate of avoidable admissions.
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Figure 10: % Emergency admissions by age group,Falkirk. Source: ISD Scotland
3.7 Delayed DischargesPeople do not want to stay in hospital longerthan needed. The Scottish Government target isthat no one should wait longer than 2 weeks tobe discharged. Unnecessary delays can lead todeterioration in an individual’s health andconsequently a potential loss in their ability toremain independent. Delays in a person’sdischarge can occur for a variety of reasons.
Figure 11:Delayed Discharges in Falkirk LA, April2014 - September 2015. Source: ISD Scotland
Figure 11 represents the number of peoplewithin Falkirk with Delayed Discharges over thetime period April 2014 until September 2015.The figure represents all delayed discharges,from and beyond one day delay.
The Falkirk Partnership is working towards thetarget of ensuring that no one stays in hospitalfor more than two weeks beyond their agreeddischarge date and will work through a numberof actions identified which will support timelyand appropriate discharge and support peoplereturning home with appropriate care whereverpossible.
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3.8 Key IssuesA detailed Joint Strategic Needs Assessment (JSNA) hasbeen completed. This provides a comprehensivedescription of health and social care information for theFalkirk HSCI Partnership.The key issues for the Partnership are: • The Falkirk area has an ageing population.The 75+ year population is projected to increase by 98%by 2037. This has significant implications for serviceprovision as over 75’s are generally intensive users ofhealth and social care. Corresponding with the growthin the older population, the working age population isexpected to decrease. This has the potential to affectthe ability to provide services. However, it is importantto note that people are living longer and healthier lives.Many people aged over 60 years are contributing tosociety through volunteering within their communityand caring for relatives.
• Workforce.The local demographics demonstrate an ageingworkforce; subsequently, the Falkirk Partnership mustconsider the workforce to ensure that planned futureservices are sustainable. The raising of the retirementage also emphasises the need to develop strategieswhich meet individual and the Falkirk Partnership’sexpectations; enabling people to work longer with bothenergy and good health so that vital skills are retained.
• It is projected that the Falkirk area will havegrowing numbers of people living with long term conditions, multiple conditions and complex needs.
There is a need to redesign services to better meet theneeds of people with complex needs. People withseveral complex long term conditions are currentlymaking multiple trips to hospital clinics to see a rangeof specialists services that are sometimesuncoordinated. This would suggest that a focus shouldbe on the holistic needs of people and developing newpathways and guidelines rather than the current diseasespecific models.
• Carers.One of the aims of Health and Social Care Integration isto keep people living independently in the communityfor longer. The projected increase in the olderpopulation and people with complex care needs is likelyto mean there will be an increasing need to supportcarers.
• Deprivation, housing and employment. High levels of public resources are spent each year onalleviating health and social problems related to peopleand families who are trapped in cycles of ill health(Christie, 2011). Consideration will be given to otherimportant factors, such as housing, unemployment andpoverty. The Partnership will adopt a whole-systemsapproach to improve health and social care outcomesand will work alongside Community Planning partners toaddress these wider issues.
May
39.5% 39.8% 39.1% 40.5% 42.9% 42.4% 44.0%39.7% 39.4% 39.1%
60.5% 60.2% 60.9% 59.5% 57.1% 57.6% 56.0%60.3% 60.6% 60.9%
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In summary, the key issues described can have animpact on the delivery and availability of servicesat a time of reductions in public spending. Forexample, services associated with emergencyhospital admissions and delays in discharge, careat home and community based services. This planwill take account of these issues and addressthem through integration and new models ofservice delivery. Further detail on the prioritiesand how we will achieve this are described inlater sections of the plan.
3.9 Policy ContextThe challenges described in this section arerecognised across Scotland. The ScottishGovernment has initiated a major legislativeprogramme of reform of public bodies to addressthese. The Integration of Health and Social Careensures that those people who use services getthe right care and support whatever their needs,at any point in their care journey.
The Falkirk Health and Social Care IntegrationStrategic Plan is a high level strategic framework.It sets out the reason for change and how we willbegin to make the transformational changes andimprovements to develop health and socialservices for adults. This will be over the nextthree years.
Key national legislation that has been consideredin the development of Falkirk’s Strategic Plan,and its outcomes and priorities include:• Public Bodies (JointWorking) (Scotland)Act 2014
• Community Empowerment (Scotland) Act 2015• Children & Young People (Scotland) Act 2014• Community Learning and Development(Scotland) Regulations 2013
• Carers Bill• Criminal Justice Bill• Audit Scotland - Health & Social CareIntegration report, December 2015
Falkirk HSCI Partnership is a statutory member ofFalkirk Community Planning Partnership (CPP)and therefore has a shared responsibility for thedelivery of the priorities and outcomes set out inthe Strategic Outcomes and Local Delivery (SOLD)Plan. The SOLD priorities and outcomes havebeen identified by looking at evidence, speakingto our communities and identifying issues withinour communities.
Priorities :• Improving mental health and wellbeing• Maximising job creation and employability• Minimising the impact of substance misuse oncommunities, families and individuals
• Tackling the impact of poverty on childrenOutcomes:• Our area will be a fairer and more equal place to live
• We will grow our local economy to securesuccessful businesses, investment andemployment
• Children will become adults who are successfuland confident
• Our population will be healthier• People live full, independent and positive liveswithin supportive communities
• Our area will be a safer place to live
The CPP will be working to achieve thesepriorities and outcomes over the next five years.On this basis the HSCI Partnership’s outcomes areembedded within the SOLD plan.
This plan takes account of the Clackmannanshireand Stirling HSCI Partnership Strategic Plan andpriorities. There are a number of NHS and LocalAuthority services which will continue to beplanned and delivered across Forth Valley wherethis makes sense to do so and will meet localneeds. Consideration has been given to specialistservices out with Forth Valley that Falkirkresidents may need.
In the development of our Strategic Plan we tookinto account the existing plans that relate tohealth and social care.
These include for example:• NHS Forth Valley Healthcare Strategic Plan• NHS Forth Valley Clinical Services Review• NHS Forth Valley Local Delivery Plan• NHS Forth Valley Winter Plan• Falkirk Council Corporate Plan• Poverty Strategy: Towards a Fairer Falkirk• Falkirk Joint Commissioning Plan for OlderPeople
• Forth Valley Integrated Carers Strategy• Drug and Alcohol Strategy• Integrated Children Services Plan• Local Housing Strategy• Falkirk Council’s Community Learning &Development Action Plan
There are a number of national strategies,including:• National Clinical Strategy• Mental Health Strategy• Keys to Life Strategy (Learning Disabilities)• Dementia Strategy• Physical Activity Strategy.
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4. People’s Views
The Strategic Plan has been developed using information about the Falkirk area, population and theirneeds. The HSCI Partnership will produce a Consultation and Engagement report on the process todevelop the Strategic Plan. In addition, the HSCI Partnership will produce a detailed FalkirkParticipation and Engagement Plan. This will outline how we will continue to engage with people andpartners to develop integrated models of service delivery.
4.1 Wider EngagementThe HSCI Partnership has listened to the views of people living in and providing services within theFalkirk area to shape the plan. We have also acknowledged the legislation and national and localpolicy and planning arrangements.
Locality planning will put people and partners at the centre of developing current and future services,which includes setting local priorities. The Falkirk Participation and Engagement Plan will describehow people can be involved.
In the development of the Strategic Plan, we have:
Table 4
Informed Engaged Consulted
Staff Newsletter
Local Media
Social Media
Website Banner
Posters in publicvenues/GP surgeries
Staff engagement sessions (7 in total April & May 2015)
Transitional Board priority settingworkshop (18 June 2015)
Stakeholder engagement event forstaff across all sectors(30 June 2015)
Strategic Planning Group meetings(August and Nov 2015 & Jan 2016)
Citizens Panel Survey (November2015, with 493 responses)
Online Survey(Nov & Dec 2015, with 73responses)
Targeted presentation and feedback sessions(23 in total throughoutNov & Dec 2015)
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The process to date has been sequenced, withinformation from each event helping to informthe next. The Strategic Planning Group thenrefined and agreed the priorities. Widerconsultation has taken place through the CitizensPanel and online surveys, during November andDecember 2015. This was also supported by 23targeted presentation and feedback sessions to arange of stakeholder groups within the Falkirkarea. These included:
Table 5
4.2 What people said future services should beConsultation and engagement events have informedthe HSCI Partnership about what future servicesshould look like, to enable people in Falkirk to livefull and positive lives within supportivecommunities. The responses from engagement onthe draft plan are summarised below.
Respondents said future services should be:• Person-centredGood services are outcomes focused, centred roundthe needs of people. People are able to makeinformed decision regarding their own care pathwayand are supported to self-manage, where possible.The transition process will be seamless and well-co-ordinated. For example, young people’s transitionfrom children’s to adult health and social careservices will begin at a point that allows sufficienttime to plan for new arrangements to be in place.Single care plans should be ‘owned’ by the serviceuser, their carers and family. Information aboutservices is co-ordinated and communicated in anaccessible way.
• Improved Access People are able to access services quickly via asingle point of contact, particularly those withmultiple or long-term conditions. Transitionbetween services is supported with a back officeinfrastructure that facilitates smooth transfer viaeffective communication and information sharing.In addition, services are responsive and availableconsistently throughout the year, on a 24/7 basis,if appropriate.
• Focused on Early Intervention People are supported by responsive, proactiveservices before reaching crisis. Education andinformation is accessible and readily available topeople, their carers and families, which allows themto make informed choices and manage their ownhealth and wellbeing. The HSCI Partnershiprecognises the critical link between traditionalhealth and social care provision and thecontribution of wider partners, for example, theCommunity Planning Partnership, Criminal Justice &Housing.
• Enhanced Information sharingInformation sharing is critical to good integratedcare – and is extended across all sectors.Information sharing includes the ability to sharesingle assessments and care plans, which are co-produced by services users and professionals, andcan be used and updated across professionalspecialisms. This allows the co-ordination of care,so that the right care is provided at the right timeby the most appropriate service. Infrastructure,particularly IT systems, are in place to support this,and staff are able to access and use the systemwith data sharing procedures in place.
• Skilled WorkforceA shared vision is held across all partners. Theworkforce across all sectors is highly skilled. Jointworking across agencies and sectors is the normand frontline staff are empowered to take decisions,which allow them to tailor response and care to suitthe needs of individuals. The HSCI Partnership isable to identify, manage and tolerate risk, and staffare supported in being able to work in differentways to help people achieve their personaloutcomes.
4.3 Further information on the consultation andengagement process to develop the Strategic Planare described in the Consultation and Engagementreport on the process to develop the Strategic Plan.The information from the Joint Strategic NeedsAssessment and the consultation has helped shapethe priorities for the partnership. These aredescribed in the following sections.
TargetAudience
Group/Forum
Communities Community Council ForumCarers ForumALFY Public Education EventsPatient Participation ForumFriends of Dundas
Staff Occupational Health ForumGP Sub CommitteeNHS Forth Valley CorporateManagement TeamCommunity Care Service ManagersMeetingPlaying to your Strengths Event
Partners NHS Forth Valley BoardFalkirk CouncilFalkirk Community PlanningPartnershipICF Project LeadsAlcohol and Drugs PartnershipCommunity Care and Health ForumScottish Care ProvidersMake it Happen ForumFife and Forth Valley CommunityJustice Authority Board
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5: How will this plan be delivered?
5.1 The Falkirk HSCI Partnership is committed to continuing our engagement with individuals andcommunities to develop high quality, responsive and effective services that improve outcomes forpeople. This section sets out how we will deliver the Strategic Plan. We will do this by:• Working with communities and our staff to develop locality plans for each of the three areas
• Continue to engage with our workforce to develop services and to provide appropriate training andsupport
• Working with Community Planning Partners and the Third and Independent sectors to develop localservices and support.
The Strategic Plan sets a direction for the next 3 years and will continue to develop in response to thechanging environment and emerging feedback from communities and partners. In order to worktowards the outcome and priorities, the following section outlines the required actions.
5.2 LocalitiesThe Strategic Plan will be realised within three different localities, namely
• Falkirk Town
• Bo’ness, Grangemouth and Braes
• Denny, Bonnybridge, Larbert and Stenhousemuir
The Falkirk HSCI Partnership will work alongside Falkirk Community Planning Partnership, includingNHS Forth Valley and Falkirk Council, to implement a locality planning framework that will mean thatlocal communities are involved in the design and implementation of new services; provided bystatutory agencies and by communities themselves. This will also support the CommunityEmpowerment (Scotland) Act.
The purpose of locality planning is to ensure that we drive change and deliver outcomes that are ofparticular importance to local communities. We will through a robust locality planning processunderpinned by local community planning identify those communities that are not achieving theoutcomes we want and identify alongside local people and providers how we can make progress onthese.
Although three health andsocial care localities have beenidentified, the CommunityPlanning Partnership will workwith a greater number ofsmaller localities across theFalkirk area, with a particularfocus on areas with high levelsof deprivation.
Local action planning that haspreviously been undertaken, inline with the local CommunityLearning and DevelopmentAction Plan 2015-2018, havehighlighted challenges andneed within communitiesbased on ‘lived experience’.
Information has been gatheredrelating to health and well-being and health inequality.The Partnership will use andbuild on this intelligence whenconsidering future communitybased provision.
5.3 Community EngagementThe HSCI Partnership willimplement our Participationand Engagement Strategy. Thisis in line with the NationalStandards of CommunityEngagement, Falkirk Council’sPlan for Local Involvement andthe Scottish Health Council’sParticipation Standard.
The Participation andEngagement Strategy sets outprinciples for participation andengagement, which will makesure that people are involved,consulted with and activelyengaged with the integrationof health and social care. Theprinciples for participation andengagement are relevant tostaff, individuals, communitiesand agencies.
This will mean that we will putpeople first and involve themin how services are redesignedto meet their individual needsand the need acrosscommunities. This engagementwith communities and partnersworking within the area willgenerate information whichwill set the scene for holisticprovision. It will link to thework of the CommunityPlanning Partnership to address
the SOLD Plan priorities andoutcomes and target forexample health improvementactivity and actions to reducehealth inequalities and supportpeople.
5.4 ServicesThe HSCI Partnership hasresponsibility for the planningand operational delivery ofhealth and social care foradults within the boundaries ofthe Falkirk Council area.
There is a range of social care,primary and secondaryhealthcare and public healthimprovement services. Thereare also several examples ofintegrated workingarrangements in place, such asthe Community Mental Health
and Learning Disability Teams.These provide valuableresources to continue todevelop integrated services andways of working.
Many initiatives are currentlybeing tested and arecontributing to local outcomes.Some of these initiatives arespecific to certain localitiesand could be rolled out acrossthe Falkirk area. Initiatives andservice redesign have been,and will continue to be,developed consistent with theoutcomes and priority areas.
The adult health and socialcare services, including thoseprovided by the Third andIndependent sectors, whichwill be within the agreed scopefor planning and delivery are:
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Current CommunityHealth Services• District Nursing• Services related tosubstance addiction
• Services provided by AHPsin outpatient clinics or outof hospital
• Primary medical services/Public dentalservice/General dental,Ophthalmic andPharmaceutical services
• Community Mental Healthand Learning Disabilityservices
Current Hospital Services• Emergency Department• Inpatient hospital services(General Medicine/GeriatricMedicine/RehabMedicine/Respiratory)
• Hospital based MentalHealth services
• Psychiatry of LearningDisability.
Current Local Authority Services
• Social work services for adultsand older people
• Services and support for adultswith physical disabilities andlearning disabilities
• Mental health services• Drug and alcohol services• Adult protection and domesticabuse
• Carers support services• Community care assessment teams• Support services• Care home services• Adult placement services• Health improvement services• Aspects of housing support,including aids and adaptations
• Day services• Local area co-ordination• Respite provision• Occupational therapy services• Re-ablement services, equipmentand Technology Enabled Care.
Table 6
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5.5 Housing Housing has an important role to play in thedelivery of coordinated, joined up and person-centred health and social care services.Successful integration of health and social careservices will require that more people will becared for and supported in a homely setting.
Falkirk has an ageing population, it is estimatedthat people over 65 years will increase by 72%from 2012 to 2037 (National Records of Scotland2012 population projections). Over the same timeperiod there will be an increase of 32% in singleperson households. The majority of thepopulation (65%) in Falkirk live in owneroccupied housing (2011 Census) which is abovethe national average (62%). In relation to olderpeople, they are more likely to own propertiesthan younger people.
It is estimated that there is a need for disabledadaptations in 2% of dwellings locally, equatingto around 1,380 properties (Scottish HouseCondition Survey 2011-13). Applying localinformation to national research, it is estimatedthat there may be a need for 510 all tenurewheelchair properties locally (Watson et al 2012).
The Housing Contribution Statement (HCS) isinformed by consultation with stakeholders andthe analysis carried out for the Housing Need andDemand Assessment. This Assessment identifiesthe contribution that specialist provision plays inenabling people to live well, with dignity andindependently for as long as possible. It isimportant to target funding to plan the deliveryof need from specialist groups; furtherinformation is available in the HousingContribution Statement which has highlighted apotential need for Extra Care Housing for olderpeople, advice and information for specialistgroups and the importance of streamliningprocedures for disabled adaptations.
The Housing Contribution Statements is anintegral part of the Strategic Plan and provides alink between the Strategic Plan and the LocalHousing Strategy.
5.6 WorkforceEffective leadership is crucial in providingdirection and delegation, enabling staff at alllevels across the HSCI Partnership to fully adopta person-centred approach to care. In addition, asystematic review and evaluation of currentservices will provide the basis for the necessarytransformational change.
Robust accountability is necessary to ensure thatthere is clarity around roles and responsibilitiesregarding reporting structures that ensure actionsare delivered. This links backs to effectiveleadership and the ability to make informeddecisions.
The Integrated Workforce plan sets out ourcommitment to ensure a workforce that isresponsive and skilled and is able to provide careand support that is local and of a high qualityconsistent with the Partnership ambitions.
The Integrated Workforce plan also sets out thecommitment to working across the wider healthand social care sector, not just those employedby the NHS or the Council. This will support theongoing joint commissioning of services and theapproach to delivering services integrated atlocal level.
This Integrated Workforce plan will be a ‘live’document and will be supported by more detailedworkforce and organisational development actionplans for localities and will reflect the ongoingIntegration Joint Board corporate and nationalpriorities.
5.7 Strategic Plan and other plansIn section 2.2, we describe the range ofpartnership and service plans in place.Importantly, public views and evidence basedapproaches informed their development, andthere was wide consultation and research onthese. The partners have individually and/orcollectively agreed to work towards these and areat different stages of completion.
These plans are a helpful starting point to focusfuture HSCI Partnership activity. This StrategicPlan takes account of the legislative strategicplanning requirements and how future local plansmust align with the integration agenda and awhole system approach.
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The Strategic Plan is supported by key documents which are available as annexes.
These are:• Clinical and Care Governance Framework
• Participation and Engagement Strategy
• Integrated Workforce Plan
• Joint Strategic Needs Assessment
• Financial Plan
• Performance Management Framework
• Risk Management Plan
• Housing Contribution Statement
• Market Facilitation Plan
5.8 Financial Statement: Partnership Budget The budget has been set taking into account the requirements of the PublicBodies (Joint Working) (Scotland) Act 2014, national guidance and theIntegration Scheme for the partnership.
The budget is made up from contributions from:
NHS Forth Valley = £131million
Falkirk Council = £61million
Partnership Funding = £8million
The Falkirk HSCI Partnership budget for 2016/17 totals £200 million.
The partnership budgets have been set taking into account:• A ‘due diligence’ process which examined the budgets and expenditure forthe 3 financial years preceding the establishment of the partnership
• National guidance on budgets for Health and Social Care Partnerships fromthe Integrated Resource Advisory Group (IRAG)
• The financial settlements to NHS Boards and Local Authorities for2016/17 from Scottish Government.
Financial and Economic OutlookThe UK Spending Review published in November 2015 and the subsequentScottish Draft Budget set out the short to medium outlook for publicfinances of year on year real term reductions in overall public expenditureuntil 2020. This financial settlement is set against the demographicpressures outlined within the Strategic Needs Assessment and the need toredesign services to meet our vision and outcomes. The Integration JointBoard is required to ensure that all of the redesigned and commissionedservices are aligned to the Strategic Plan priorities.
The partnership will develop a Financial Plan to underpin the Strategic Plansetting out how it will intend to best utilise the resources available to meetthe priorities stated within this plan. It is the intention to develop aFinancial Plan covering 3 years to allow medium to longer term serviceplanning.
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5.9 Risk Management The Strategic Plan will be underpinned by a Risk Management Strategy. Thiswill provide staff with the necessary structure to assess and manage risk.Such an approach will be adopted at all levels of the HSCI Partnership toinclude management decisions and front line services with consideration ofservice users’ and carers’ views.
5.10 Equalities and DiversityTaking equalities into account is important as the demographics and needsof individuals and communities can be different and can change. It isnecessary to consider equalities and diversity so that the Strategic Plan canhave a positive impact on people that take account of their personalprotected characteristics.
The HSCI Partnership will complete an equality impact assessment when theIntegration Joint Board (IJB) is making a decision which is likely to impacton people. This will cover any new or revisions to strategies, policies,strategic plans, major programmes, projects, budget and service decisionswhich are likely to impact on staff and /or service users. The IJB will alsopublish a set of equality outcomes and prepare a mainstreaming report.
5.11 Market Facilitation PlanThe Strategic Plan will be underpinned by a Market Facilitation Plan. Theplan will give the Partnership a good understanding of the current levels ofneed and demand for health and social care services. This will then help usto identify what the future demand for care and support might look like andhelp support and shape the market. This will ensure there is a diverse,appropriate and affordable provision available to deliver effective outcomesand to meet needs.
The plan will represent the dialogue with service providers, service users,carers and other stakeholders about the future shape of our local social careand support market. By implementing the plan, we can ensure that we areresponsive to the changing needs and aspirations of Falkirk’s residents.
5.12 Performance Management and ReportingPerformance management is necessary to ensure the efficiency,effectiveness and quality of services and that these are regularly evaluatedand monitored. This will include evaluating collaborative working withinand across all sectors.
The IJB will be held accountable for all services within their responsibilityand need to publish an annual performance report. This will set out how thepartnership is improving the National Health and Wellbeing Outcomes.
The Scottish Government has set out a range of core integration indicatorsto guide us (see Appendix 1). These are based on survey feedback, toemphasise the importance of a personal outcomes approach and the keyrole of user feedback in improving quality. While national user feedback willonly be available every 2 years, we will supplement performance reportswith local information that is collected more often.
Additionally a local suite of performance indicators will monitor progressagainst outcomes and priorities. Regular performance reports will besubmitted to the Integration Joint Board. These will be included in theannual performance report.
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AANNEE FFOORR AA''
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March 2016